Determinants of breakfast skipping among pregnant women from South Ethiopia Gamo Zone: a case-control study

Abstract

Skipping breakfast during pregnancy presents several challenges and potential health risks for both the mother and her baby. Breakfast plays a crucial role in providing essential nutrients and energy after an overnight fast. Skipping breakfast during pregnancy creates an unhealthy environment for the fetus. Thus, this study aimed to identify the determinants of breakfast skipping among pregnant women. An unmatched, community-based case-control study was conducted among 116 randomly selected cases (breakfast skippers) and 232 neighboring controls (regular breakfast consumers). Data was collected using pre-tested interviewer-administered structured questionnaire. Binary logistic regression analysis was employed to determine predictors of breakfast skipping using STATA version 16. The odds of non-formal education (AOR = 3.92; 95% CI: 1.75, 8.78), low socioeconomic status (AOR = 2.93; 95% CI: 1.12, 7.68), poor dietary knowledge (AOR = 2.89; 95% CI: 1.29, 6.47), and experiencing morning sickness (AOR = 2.57; 95% CI: 1.13, 5.84) were higher among cases than controls. The odds of breakfast skipping were higher for every increase in family size (AOR = 1.65; 95% CI: 1.25, 2.18), but decrease with every unit increase in mid-upper arm circumference (AOR = 0.58; 95% CI: 0.46, 0.72) and weekly frequency of drinking coffee leaf tea beverage (AOR = 0.84; 95% CI: 0.78, 0.89). Findings of this study showed that poor economic status, lack of formal education, poor dietary knowledge, having morning sickness, having large family size, maternal nutritional status, and frequent consumption of coffee leaf tea beverage were significantly associated with breakfast skipping among pregnant women. Thus, efforts should focus on improving dietary awareness during pregnancy, strengthening dietary counseling during antenatal care, enhancing access to contraceptive services, and ensuring timely management of morning sickness.

Introduction

Breakfast is food or a beverage from at least one food group consumed within 2 to 3 h of waking^1,2. It provides essential nutrients^2,3 and is considered a central part of daily nutritional needs⁴. Regular breakfast consumption increases intake of carbohydrates, dairy, fiber, and most micronutrients, while reducing intake of sugar, saturated fat, and cholesterol^3,5. Generally, it improves overall healthy dietary practices¹. and contributes to metabolism and endocrine regulation⁴. Consequently, it decreases the risk of adverse effects related to glucose and insulin metabolism⁵.

Meal Skipping refers to missing one or more traditional main meals (breakfast, lunch, dinner) throughout the day⁶. Frequency of meals affects the nutrient adequacy and quality; an increase in meal per day can improves nutrient adequacy and quality index up to 5.35 points^7,8, but it was common among adults. Evidence indicated that 4.8 to 83.3% of global adult’s age 18 to 34 years⁶, 47.4% of Australians young adult⁹, and 9.74% of Chinese adults skip their meal¹⁰. Meal skipping disturbs timing of dietary intake which is a powerful signal for circadian system^11,12. Unmatched meal timing result in circadian rhythm conflicts and affect the function of various organs^11,12. Night-eating after skipping meal leads to suppression of melatonin secretion conveys oxidative stress, which leads to cellular component damage and premature placental aging, consequently increases the risk adverse birth outcome^11–13 in addition high energy intake at night elevates inflammation and glucose levels that cause uterine activation and low birth weight¹³.

In the recent decade, skipping breakfast has become prevalent among young adults aged 18 to 30 years, with rates ranging from 14 to 88.5% worldwide^6,14, 52.8 − 86.5% in Saudi Arabia¹⁵, 83.6% in Jordan¹⁵, 64.6% in Philippines¹⁵, 64.2% in Syria¹⁵, 63.0% in Egypt¹⁵, 62.1% in Yemen¹⁵, 55.0% in Australia¹⁶, 50.0% in Pakistan, 28.3− 30% in Japan¹⁷, 14.0% in Bangladesh¹⁵, 21.63% in Korean¹⁸, and 13.1 − 61% in USA^5,19,20.

The prevalence of breakfast skipping among pregnant women was 21.1–35.6% in Singapore²¹, 4.7 to 10.7% in Brazil²², 30- 38.1% In Japan^23,24, 67% in USA²⁵, and 10.1–43.18% in Ethiopia^26,27. These individuals did not meet two-thirds of the recommended dietary allowance for vitamins and minerals^5,22.

Skipping breakfast is associated with weight gain^19,28, larger waist circumferences¹⁴, higher fasting insulin levels¹⁴, higher low-density lipoprotein (LDL)²⁹, reduced high-density lipoprotein cholesterol (HDL-C)³⁰, higher cholesterol concentrations¹⁹, unhealthy behaviors like smoking, alcohol use^19,30, metabolic syndrome³⁰, asymptomatic proteinuria², fatigue²⁸, insomnia², infrequent exercise^19,30, underweight²⁸, increase risk of gestational diabetics²¹, increases the risk of cardiovascular disease, stroke, and cerebral hemorrhage³¹, raised blood pressure & fasting glucose³⁰, increase the risk of gynecologic disorders¹⁷ and increase risk of mortality¹⁹.

A large meal after breakfast skipping elevates serum insulin levels, free fatty acid levels, and de novo lipogenesis, which affect the energy levels of the placenta and fetus, leading to low birth weight³². In addition, it affects corticotrophin-releasing hormone (CRH) levels, which are responsible for early labor initiation, leading to prematurity³³. It also creates an unhealthy environment for the fetus^4,25, reduces levels of omega-3 fatty acids (EPA, DHA), and beta-carotene, which inhibit fetal brain and lung development, consequently causing low birth weight²³.

Daily breakfasts increases the consumption of diversified foods, improve appetite, satiety and reduces the risk of permanent metabolic disorder and adverse birth outcome³⁴. But it is not considered in many dietary guidelines and nutritional interventions. breakfast skipping leads to malnutrition in pregnant women, which affects the health of their children and future generations through health, economic and humanitarian consequences³⁵. The problem was extremely sever in low and middle income countries where burden of poverty and food insecurity high.

Comprehensive understanding of the factors associated with breakfast skipping during pregnancy is crucial for developing nutritional intervention strategies and address the problem. Despite studies conducted in various parts of the world, there has been no previous research specifically addressing the determinants of breakfast skipping among pregnant women. This study aims to identify the risk factors for breakfast skipping to formulate relevant policies and intervention strategies aimed at reducing maternal and child morbidity and mortality.

Methods

Study setting

An unmatched, community-based case-control study was conducted from October 1st 2023 to March 1st 2024 among pregnant women at the Arba Minch Health and Demographic Surveillance site (AM-HDSS). The study participants were enrolled in their 16 to 20 weeks of gestation.

AM-HDSS is active in the Arba Minch Zurea and Gacho Baba districts. Arba Minch Zurea district is 437 KM, and Gacho Baba district is 479 km far south of Addis Ababa, the capital city of Ethiopia. The site includes nine kebeles, six of which are from Arba Minch Zurea district and three from Gacho Baba district.

A total of 2,598 women are expected to be pregnant in the surveillance site for the year 2023/24. These women receive healthcare services at 7 nearby health centers, 37 health posts, and different levels of private healthcare facilities.

Source population and study population

All pregnant women found in AM-HDSS were the source population while all selected pregnant women found in AM-HDSS were the study population. Cases were all randomly selected pregnant women who skipped their breakfast at least three days per week whereas controls were routine breakfast consumers.

Sample size determination and sampling procedure

The sample size was determined using two-population proportion formula by assuming 95% CI, 80% power, case to control ratio of 1:2, and the expected proportion of pregnant women attending College/University among case and control were 10.53% & 24.16% respectively (24).

Where.

n = Desired number of samples.

r = Control to cases ratio.

P* = Proportion of population = (P₁ + P₂)/2 = 0.17345.

Z_1-β = the desired power 80% power = 0.84.

Z_1‑a/2 = Standard value for 95% CI = 1.96.

P₁ = Expected Proportion among cases = 0.1053.

P₂ = Expected Proportion among controls = 0.2416.

The calculated sample was 243 (81 cases and 162 controls). However, as there were 116 pregnant women who had skipped their breakfast three times per week from the longitudinal data, 116 cases and the corresponding 232 controls were included into the analysis.

The sample was allocated proportional to each kebeles based on expected number of pregnant women. Simple random sampling technique was used to recruit pregnant women with appropriate dietary practice (unexposed) and the neighboring pregnant women with inappropriate dietary practice considered as exposed for cohort study. All women who skipped their breakfast at least three days a week were identified as cases, and two neighboring controls (regular breakfast consumers) were selected using simple random sampling.

Data collection procedures

A pre-tested, face-to-face interviewer-administered structured questionnaire was used to collect data on socio-demographic, health related, and dietary factors. Dietary practice was assessed using validated food frequency questionnaire (FFQ) made of 46 food items grouped in to ten food groups. Data was collected digitally using open source toolkit (kobo Collect) by trained data collectors. A prepared template of questionnaire was deployed to the server and download to the cell phones of data collectors. And the filled data were uploaded to the server.

Operational definitions and measurement

Breakfast skipping

All pregnant women were classified based on the number of days they skipped breakfast, and those who skipped breakfast three or more days a week are considered skippers²¹.

Meal frequency

All pregnant women were classified based on the number meals consumed per day and those who consume a meal more than 3 times per day categorized as adequate meal frequency otherwise as inadequate^36,37.

Minimum dietary diversity for women (MDDW)

Pregnant women eating at least 5 of the 10 food groups over the past a 24-hour is classified as adequate minimum diet diversity^38,39.

Animal source food consumption [ASF]

Animal source food consumption is estimated by summing all animal source food pregnant women consumed over the previse 7 days and converted in to terciles. Those pregnant mothers in the upper tercile categorized as having a “high” whereas the others as having “low”⁴⁰.

Maternal dietary knowledge

Knowledge was assessed using knowledge questions developed from other similar studies. Incorrect response was recodes as “0 = not having awareness” and correct response was recodes as “1 = having awareness” with the maximum score and minimum score. Mothers who scored less than 60% considered as having “poor knowledge”, 60–79% considered as “moderate knowledge”, and greater than or equal to 80% considered as having “good knowledge”⁴¹.

Household wealth status

Household wealth status was determined using items adapted from the 2016 Ethiopia Demographic and Health Survey (EDHS), which included the number of livestock owned, the availability of agricultural land, the materials used to construct the house (floor, walls, and roof), the source of drinking water, the presence of electricity, the type of cooking fuel used, and the ownership of modern household goods, and livestock (e.g., bicycle, television, radio, motorcycle, sewing machine, telephone, car, refrigerator, mattress, bed, and mobile phone). The assumption was that the possession of these assets, services, and amenities is related to the relative economic position of the household⁴².

Data process and analysis

Data were checked online, approved for its consistency and completeness on a daily basis. After data collection was completed, the data were downloaded and exported to STATA 16.0 version statistical software for analysis. Principal component analysis was used to determine socio-economic status of the individual households and maternal dietary knowledge.

Bivariate analysis was employed and all independent variables which have an association with the outcome variable at p-value less than 0.25 in bivariate analysis were included in the multivariable model. Then, a multivariable analysis was done to determine independent determinants of breakfast skipping. Odds ratio with 95% CI was used to decide whether those explanatory variables included in the multivariable analysis were statistically significant or not. Model fitness was checked using Hosmer and Lemeshow goodness of fitness test (P = 0.98). Multicollinearity among independent variables was checked using variance inflation factor (VIF) the maximum VIF was 1.9.

Results

Socio-demographic characteristics of the study participants

Three hundred forty-eight study participants (116 cases and 232 controls) were included in the study. The mean age of the participants was 26.41 ± 5.61 years (25.65 years for case and 26.79 years for controls). Three hundred thirteen 86.21% of cases and 91.81% of controls were rural dwellers. Most of the cases 96 (82.76%) and controls 185 (79.74%) were between the age of 20 to 35 years. Two hundred seventy-two (75.86%) of cases and 79.31% of controls were housewives. Almost one third 25.86% of cases and 39.66% of controls were from high economic status (Table 1).

Table 1.

Socio-demographic characteristics of the study participants in AM-HDSS, Gamo Zone of South Ethiopia.

Variable	Participant No (%)	Case No (%)	Control No (%)	P-value
Age of the respondent
Less than 20 years	41 (11.78)	14(12.07)	27 (11.64)	0.51
20 to 35 years	281 (80.75)	96 (82.76)	185 (79.74)
36 years and more	26 (7.47)	6 (5.17)	20 (8.62)
Place of residence
Rural	313 (89.94)	100 (86.21)	213 (91.81)	0.10
Urban	35 (10.06)	16 (13.79)	19 (8.19)
Religion of the respondent
Orthodox	75 (21.55)	32 (27.59)	43 (18.53)	0.05
Protestant	273 (78.45)	84 (72.41)	189 (81.47)
Educational status
No read and write	105 (30.17)	29 (25.00)	76 (32.76)	0.06
Read and write only	25 (7.18)	6(5.17)	19 (8.19)
Primary	119 (34.20)	52 (44.83)	67 (28.88)
Secondary	76 (21.84)	22 (18.97)	54 (23.28)
College and above	23 (6.61)	7 (6.03)	16 (6.90)
Occupation of the respondent
Government employ	34 (9.77)	8 (6.90)	26 (11.21)	0.07
House wife	272 (78.16)	88 (75.86)	184 (79.31)
Merchant	42 (12.07)	20 (17.24)	22 (9.48)
Household decision making power
Both husband and wife	75 (21.55)	26 (22.41)	49 (21.12)	0.78
Mainly by husband	273 (78.45)	90 (77.59)	183 (78.88)
Number of family members
Less than five	183 (52.59)	38 (32.76)	145 (62.50)	0.49
Five and more	165 (47.41)	78 (67.24)	87 (37.50)
Household wealth status
Low	108 (31.03)	44 (37.93)	64 (27.59)	0.12
Middle	118 (33.91)	42 (36.21)	76 (32.76)
High	122 (35.06)	30 (25.86)	92 (39.66)
Dietary knowledge of the respondent
Had poor knowledge	122 (35.06)	49 (42.24)	73 (31.47)	0.14
Had moderate knowledge	174 (50.00)	52 (44.83)	122 (52.59)
Had good knowledge	52 (14.94)	15 (12.93)	37 (15.95)

Health related characteristics of the study participants

Two hundred twenty-three 66 (56.90%) cases’ and 157 (67.67%) controls’ reported that their current pregnancies were pre-planned. Almost 1/3 of cases and controls do not visit health facility for anti natal care (ANC). More than half (65.52%) of cases and 118 (50.86%) controls were developed mild to severe morning sickness during the current pregnancy (Table 2).

Table 2.

Health related characteristics of the study participants in AM-HDSS, Gamo Zone of South Ethiopia.

Variable	Participant No (%)	Case No (%)	Control No (%)	P-value
Number of pregnancy
Primigravida	70 (20.11)	23 (19.83)	47 (20.26)	0.47
Multigravida	218 (62.64)	69 (59.48)	149 (64.22)
Grand Multi	60 (17.24)	24 (20.69)	36 (15.52)
Number of delivery
Primipara	91 (33.21)	29 (32.22)	62 (33.70)	0.06
Multipara	151 (55.11)	56 (62.22)	95 (51.63)
Grand Multipara	32 (11.68)	5 (5.56)	27 (14.67)
Pregnancy interval
2 years and more	62 (33.88)	48 (39.34)	14 (22.95)	0.03
Less than 2 years	121 (66.12)	74 (60.66)	47 (77.05)
Pregnancy status
Planned	223 (64.08)	66 (56.90)	157 (67.67)	0.05
Unplanned	125 (35.92)	50 (43.10)	75 (32.33)
Antenatal care visit
Yes	233 (66.95)	77 (66.38)	156 (67.24)	0.87
No	115 (33.05)	39 (33.62)	76 (32.76)
Had morning sickness
Yes	194 (55.75)	76 (65.52)	118 (50.86)	0.01
No	154 (44.25)	40 (34.48)	114 (49.14)
History of illness during pregnancy
Yes	34 (9.77)	15 (12.93)	19 (8.19)	0.16
No	314 (90.23)	101(87.07)	213 (91.81)

Dietary and behavior related characteristics of the study participants

All participants had no history of tobacco smoking, but 10 (8.62%) of cases and 8 (3.45%) of controls drank locally prepared alcohol. Majority of the respondents 83 (71.55%) of cases and 149 (64.22) of controls consume five or more food groups 24-hours prior to data collection. Seventy two 62.07% of cases and 146 (62.93%) of controls consumed food from animal source at least ones in a week. Over three fourth 86.78% of the study participants consumed locally prepared coffee leaf tea beverage, and 85.63% were not obtained dietary information during pregnancy (Table 3).

Table 3.

Dietary related characteristics of the study participants in AM-HDSS, Gamo Zone of South Ethiopia.

Variable	Participant No (%)	Case No (%)	Control No (%)	P-value
Meal frequency
Two	14 (4.02)	10 (8.62)	4 (1.72)	0.01
Three	97 (27.87)	32 (27.59)	65 (28.02)
Four and more	237 (68.10)	74 (63.79)	163 (70.26)
Consumption of diversified food
No	116 (33.33)	33 (28.45)	83 (35.78)	0.17
Yes	232 (66.67)	83 (71.55)	149 (64.22)
Animal source food Consumption
Low	130 (37.36)	44 (37.93)	86 (37.07)	0.87
High	218 (62.64)	72 (62.07)	146 (62.93)
Currently drinking tea
Yes	116 (33.33)	37 (31.90)	79 (34.05)	0.68
No	232 (66.67)	79 (68.10)	153 (65.95)
Drink local alcohol (Tella/Tej)
Yes	18 (5.17)	10 (8.62)	8 (3.45)	0.04
No	330 (94.83)	106 (91.38)	224 (96.55)
Currently drinking coffee
Yes	155 (44.54)	38 (32.76)	117 (50.43)	0.01
No	193 (55.46)	78 (67.24)	115 (49.57)
Currently drinking coffee leaf tea beverage
Yes	302 (86.78)	94 (81.03)	208 (89.66)	0.03
No	46 (13.22)	22 (18.97)	24 (10.34)
Had crave in this pregnancy
Yes	19 (5.46)	2 (1.72)	17 (7.33)	0.03
No	329 (94.54)	114 (98.28)	215 (92.67)
Had food aversion
Yes	51 (14.66)	24 (20.69)	27 (11.64)	0.02
No	297 (85.34)	92 (79.31)	205 (88.36)
Obtained dietary information during ANC
Yes	50 (14.37)	13 (11.21)	37 (15.95)	0.24
No	298 (85.63)	103 (88.79)	195 (84.05)
Iron folic acid supplementation
Yes	219 (62.93)	73 (62.93)	146 (62.93)	1.00
No	129 (37.07)	43 (37.07)	86 (37.07)

Determinants of skipping breakfast

The odds of non-formal education was 3.92 times higher among cases than controls as compared to attending formal education [AOR = 3.92 (1.75, 8.78)]. The odds of low socio economic status was 2.93 times higher among cases than controls as compared to high socio economic status [AOR = 2.93 (1.12, 7.68)]. The odds of having dietary knowledge was 2.89 times higher among cases than controls as compared to their counterpart [AOR = 2.89 (1.29, 6.47)]. The odds of having morning sickness were 2.57 times higher among cases than controls as compared to those who do not have morning sickness [AOR = 2.57 (1.13, 5.84)]. The odds of breakfast skipping was 1.65 times higher as number of family member increased by one [AOR = 1.65 (1.25, 2.18)]. For every 1 cm increase in MUAC, pregnant women were 42% less likely to skip breakfast [AOR = 0.58 (0.46, 0.72)]. For every increase in weekly frequency of drinking coffee leaf tea beverage, the odds of skipping breakfast were reduced by 16% [AOR = 0.84 (0.78, 0.89)] (Table 4).

Table 4.

Determinants of skipping breakfast among pregnant women in AM-HDSS, Gamo Zone of South Ethiopia.

Variable	Case Mean (SD) No (%)	Control Mean (SD) No (%)	COR (95% CI)	AOR (95% CI)
Place of residence
Rural	100 (86.21)	213 (91.81)	Ref	Ref
Urban	16 (13.79)	19 (8.19)	1.79 (0.88, 3.64)	0.75 (0.16, 3.50)
Educational status
No formal education	58 (50.00).	72 (31.03).	2.22 (1.41, 3.51)**	3.92 (1.75, 8.78)**
Formal education	58 (50.00).	160 (68.97)	Ref	Ref
Household wealth status
Low	44 (37.93)	64 (27.59)	2.11 (1.20, 3.70)**	2.93 (1.12, 7.68)*
Middle	42 (36.21)	76 (32.76)	1.69 (0.97, 2.96)	2.26 (0.86, 5.97)
High	30 (25.86)	92 (39.66)	Ref	Ref
Had dietary knowledge
No	49 (42.24)	73 (31.47)	1.59 (1.01, 2.53)*	2.89 (1.29, 6.47)**
Yes	67 (57.76)	159 (68.53)	Ref	Ref
Current pregnancy
Planned	66 (56.90)	157 (67.67)	Ref	Ref
Unplanned	50 (43.10)	75 (32.33)	1.58 (1.02, 2.51)*	1.50 (0.65, 3.44)
Obtained dietary information during ANC
Yes	13 (11.21)	37 (15.95)	0.66 (0.34, 1.31)	0.53 (0.15, 1.80)
No	103 (88.79)	195 (84.05)	Ref	Ref
Had food aversion
Yes	24 (20.69)	27 (11.64)	1.98 (1.08, 3.61)*	2.90 (0.86, 9.80)
No	92 (79.31)	205 (88.36)	Ref	Ref
Had morning sickness
Yes	118 (50.86)	76 (65.52)	1.83 (1.16, 2.91)**	2.57 (1.13, 5.84)*
No	114 (49.14)	40 (34.48)	Ref	Ref
History of illness during pregnancy
Yes	15 (12.93)	19 (8.19)	1.66 (0.81, 3.41)	1.60 (0.45, 5.68)
No	101(87.07)	213 (91.81)	Ref	Ref
Drink local alcohol (Tella/Tej)
Yes	10 (8.62)	8 (3.45)	2.64 (1.01, 6.88)*	4.09 (0.54, 30.73)
No	106 (91.38)	224 (96.55)	Ref	Ref
Family size	5.59 (1.86)	3.97 (1.52)	1.74 (1.49, 2.02)*	1.65 (1.25, 2.18)**
Mid upper arm circumference	22.62 (1.92)	24.35 (2.71)	0.72 (0.64, 0.81)**	0.58 (0.46, 0.72)**
Weekly frequency of drinking coffee leaf tea beverage	n = 94 11 (5)	n = 208 14.87(6.56)	0.91 (0.86, 0.94)**	0.84 (0.78, 0.89)**

COR crude odds ratio, AOR adjusted odds ratio, Ref reference Group, n sample size, SD standard deviation

*P-value < 0.05, **P-value < 0.01

Discussion

This study revealed that a total of 237 (68%) pregnant women, 74 (63%) breakfast skippers and 163 (70%) non-skippers, consumed meals (main and snacks) more than three times per day. This finding was higher than the findings from Northern Ethiopia 18.4%³⁷, and Eastern Ethiopia 26.12%⁴⁰. The consumption of meals more than three times per day after skipping breakfast is an indicator that late evening dietary intake is common among breakfast-skipping women^11–13.

Education is a way to learn about healthy and quality dietary practices and as the level of education increases, so does exposure to health information and health service utilization⁴³. This can lead to improved maternal health care during pregnancy and a decrease in unhealthy eating behaviors such as skipping breakfast⁴⁴. In our finding the odds of non-formal education was about 4 times higher among cases than controls as compared to those who attend formal education. This is consistent with study’s findings from Japanese pregnant women^23,24,45. Also studies conducted in china and Australia point out meal skipping was lower among educated adults^9,10. In contrast studies from Australian adolescent and Korea adult indicates breakfast skipping was higher among educated participant^16,30. However, the study conducted in Saudi Arabia indicates non-significant association between breakfast skipping and level of education¹⁵.

A qualitative study in Ethiopia indicated that financial constraint and household income is a common barrier for dietary intake during pregnancy⁴⁶. In this study, the odds of low socioeconomic status were higher among cases than controls as compared to high socioeconomic status. This is a known fact that a state of wealth helps to meet basic human needs, access to health services, and adequate food intake in frequency and quality⁴⁷. This can lead to individuals with lower socio-economic status skip breakfast due to the lack of money to purchase food. This finding was consistent with studies conducted in Australia and china^10,16 but inconsistent with studies conducted in Saudi Arabia Korea and Japan^15,30,45. This discrepancy might be due to socio-economic and socio-cultural difference.

In the current study, the odds of having poor dietary knowledge during pregnancy were about three times higher among cases than controls, compared to those who had better dietary knowledge. It is the fact that dietary knowledge is essential to create cognizance about better dietary practice^48,49. Similar findings have been observed among Japanese adults⁴⁸. In contrast, a systematic review conducted among children and adolescents found no association between nutrition knowledge and dietary and eating behavior⁵⁰. This is likely due to differences in the study settings.

In this study, the odds of morning sickness were higher among cases than controls compared to those who did not have morning sickness during the current pregnancy. This is likely due to the maternal-embryo protection hypothesis, which suggests that strong smells in the environment or unpleasant tastes in food induce nausea and vomiting to expel potentially toxic chemicals, thereby leading to skip breakfast⁵¹. Additionally, cultural influences, prevention of metabolic syndrome, taste aversion learning, changes in taste sensitivity, hormonal effects, and physiological impacts are more pronounced immediately upon waking from sleep. Consequently, this often leads to delays or skipping breakfast^{46,47,52–54}.

In the current study, as the number of household members increased by one, the likelihood of breakfast skipping also increased by 2.  This highlights the fact that as the number of family members increases, it strains family resources, leading to depletion in food availability and consequent breakfast skipping. This issue is severe among households living below the food poverty line, resulting in inadequate dietary practices, particularly noticeable in larger families^55,56.

This study found that for every one increase in the weekly frequency of drinking coffee leaf tea beverage, the odds of skipping breakfast were reduced by 16%. This is likely due to the composition of locally prepared coffee leaf tea beverage, which includes ingredients such as ginger, garlic, rosemary, African wormwood, anise, Artemisia abyssinica, thyme, coriander, and roasted coffee leaves. The ginger in the coffee leaf tea beverage acts as an anti-emetic, thereby reducing the likelihood of skipping breakfast^57,58. Also the biochemical content of coffee leaf tea beverage, such as antioxidants that suppress nausea and vomiting^59,60, along with its ethnomedicinal effects (anti-inflammatory, anti-hypertensive, anti-bacterial, and anti-fungal activities), contribute to reducing poor appetite and consequently decrease meal skipping⁶¹.

In this study, the odds of breakfast skipping were reduced as MUAC increased. This is a known fact that dietary intake is associated with nutritional status⁶². As the quality and quantity of dietary intake declines, the incidence of malnutrition increases, and skipping breakfast is a common cause of inadequate dietary intake. Our finding was consistent with study conducted in Ethiopia in which meal skipping is associated with under nutrition³⁵. But some studies indicated that there is no statistical association between meal frequency and under nutrition^34,36,63. The implication of these findings is that improved knowledge about dietary practices during pregnancy, gained through formal education and nutritional advice, along with regular breakfast habits achieved through higher wealth status, reduced morning sickness, and increased coffee leaf tea beverage consumption could enhance nutritional status during pregnancy.

Limitation

The information on dietary practice relay on memory of the women subjected to recall bias, misclassification bias and social desirable bias. Furthermore, the study did not address the amount, nutrient content, and quality of breakfast; further research is needed to examine these aspects.

Conclusion

This research identified several factors independently associated with pregnant women breakfast skipping, including wealth and educational status, dietary knowledge, having morning sickness, family size, maternal nutritional status measured by MUAC, and frequency of consuming coffee-leaf tea. Targeting these factors is essential to promote regular breakfast habits among pregnant women. Additionally, efforts should focus on improving dietary awareness during pregnancy, strengthening dietary counseling during antenatal care, enhancing access to contraceptive services, and ensuring timely management of morning sickness. Also, encouraging the consumption of locally prepared, nutrient-rich and ethno medicine beverage (coffee leaf tea beverage) consumption can also be beneficial. Furthermore, scholars should address the effects of breakfast skipping and coffee leaf tea beverage on maternal and fetal outcomes.

Author contributions

TF conceptualize and designed the study, conducted the analysis, interpret and write the first draft of the paper for publication. DT and BWA advise and involve in the overall process. All authors read and approved the final manuscript.

Funding

Jimma University supported this research financially. The university has no role in the design of the study, collection, analysis, and interpretation of the data and in the writing the manuscript.

Data availability

All relevant data are within the paper. However, if additional information is required, it will be provided upon request from corresponding author.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical approval was obtained from Jimma University Institute of Health Institutional Research Ethics Review Board (IRB), with letter reference number (Nut/5029/2023). Letter of cooperation was obtained from Gamo zone health office. Formal letters and permissions were secured from all respective local administrators. All pregnant women were linked to the health facility for ANC and dietary information and nutritional education was provided according to WHO 2016 ANC guideline. Informed consent was obtained from the study participants. To ensure confidentiality, their names, and other personal identifiers were not registered in the survey tool.